Archive for August, 2012

Marathon runners can have race-related major medical problems; most don't.

I recently read an article on patents who appear to have Alzheimer's when they present to a physician's office or an Emergency Room, but actually have some other disease or problem. An old friend visiting now us is an ER doc and said, "I see that all the time; it's usually hyponatremia,"

As a nephrologist, I've also seen a number of patients with mild to severe hyponatremia ,i.e., a relatively low blood sodium concentration, said to be the most common metabolic problem seen in the United States. The normal numbers are 135 to 145; anything under 130 is termed severe hyponatremia; under 120 is critical, life-threatening hyponatremia.

In doing my background research, I found a Boston Globe article on a tragedy that occurred in the 2002 Boston Marathon. So I'll follow that thread for this post and discuss background data on other sodium issues later.

Most of us are familiar with a marathon as a long-distance race; actually it's 26 miles and 385 yards (there's a fascinating story behind that being the distance) and world record times are just over two hours for men and about twelve minutes longer for women.

In that 2002 race, one relatively inexperienced runner (this was only her second race at that distance) seemed to be doing well six miles from the finish, but then started to have problems. She told a friend she felt rubber-legged and dehydrated. Then she collapsed, became comatose and died. The autopsy conclusion was that hyponatremia secondary to drinking too much Gatorade had precipitated brain swelling that led to her death. She was only the second death in the over 100-year history of that marathon. Blood samples were studied by a Harvard staff physician and five years later in the American Journal of Medicine that physician and collaborators published an article, "Hyponatremia due to SIADH in Runners,"

So what does that weird acronym mean? It stands for Syndrome of Inappropriate Anti-Diuretic Hormone (ADH) secretion. Let's start from scratch even if I get too basic. A syndrome is a group of symptoms and signs (the latter being observed by a second person) that together characterize a disease or disorder. A diruetic is something that increases urine flow. A hormone is a chemical produced by a gland or cell in our bodies that has an effect on other cells or tissues.

ADH is secreted by the pituitary gland, a pea-sized structure at the base of the skull that has so many functions it's sometimes called the master gland. This particular hormone controls the ability of water to pass through the cells in the walls of tubules in the kidneys and therefore be retained in the body. If no ADH is present, then no water can pass through those walls. The more ADH present, the more water can pass through.

An October, 2005, article in The New York Times was titled "Marathoners Warned About Too Much Water." But most who run the distance, even those who feel puny at some point and seek medical help for non-injury reasons, have normal to slightly high sodium levels. They've lost a little weight through sweating, but the medical director of the NYC marathon stated, "There are no reported cases of dehydration causing death in the history of world running." NB. The four deaths in the 2005 Great North Run in England on a warm, sunny day have been cited to be dehydration-related, but not by medical evidence that I've been able to find.

On the other hand, a 2005 article in the New England Journal of Medicine, looking at "Hyponatremia among Runners in the Boston Marathon," enrolled 766 participants in the 2002 race, did not measure their sodium levels before the gun sounded, but 511 came to the research station at the finish line and 489 of those gave a blood sample (most of the ones who didn't had a close connection for an airplane flight).

Thirteen percent had low sodium levels, with 37 of 166 women (22 percent) and 25 of 322 men (8 percent) in that group. Three had sodium levels under 120. Hyponatremia was strongly tied to weight gain, so the authors' conclusion was they were drinking too much water or sports drinks (it's important to realize that these have a relatively low sodium content).

Over-loading with fluids can lead to serious problems.

The Harvard researcher and his co-authors termed this as exercise-associated hyponatremia (EAD), measured ADH levels and those of Interleukin-6, a protein that's released from damaged muscles and can lead to ADH secretion. They concluded that EAD cases meet the criteria for SIADH. An increase of 3% of the runners' body weight would correlate to a decrease in serum sodium to less than 130.

So how do we avoid more hyponatremic deaths among marathon runners? Education seems the primary answer and perhaps weighing slower runners during the race. I can envision a scale a runner steps on (without stopping) with a relay of information to a point a short distance further on where race advisors could shout, "Number 3277, quit drinking any more fluids."

Some take the pills; others use the rolled-up twenty to inhale illicit drugs

I'm home and working on my Mac laptop, so I can add a few links and photos to this post. Let's start with a New York Times article dated May 11, 2012 that caused a huge flap. Ian Urbina, a senior NYT reporter is no stranger to controversy, but his article titled, "Addiction Diagnoses May Rise Under Guideline Changes," prompted an unusually strong response from the American Psychiatric Association (APA), the group responsible for revisions to DSM.

Urbina interviewed a number of senior figures in the field and wrote that the new version by expanding the list of associated symptoms in alcohol and drug addiction, adding a new "gambling addiction" diagnosis, and possibly even pasting in an NOS (not otherwise specified) category for "behavioral addiction," could add as many as 20 to 30 million people to those fitting under DSM's umbrella of illnesses.

He quoted Dr. James H. Scully, Jr. the APA's Chief Executive Officer and Medical Director at American Psychiatric Association, as saying "The biggest problem in all of psychiatry is untreated illness and that has huge social (sic) costs."

Others with considerable stature in the mental health (MH) field had qualms. Dr. Allen Frances, head of the DSM-IV revision team, stated , "We'll see false epidemics and medicalization of everyday behavior". Researchers in Australia estimated 60% more people would be considered alcohol addicted under DSM-5's definitions, while a health writer at TIME.com said the new manual could lead to 40% of college students being called alcoholics.

The APA responded with a bit by bit rebuttal of Urbina's article. They noted that DSM-5's terminology would be "substance abuse disorder," not addiction and expected early intervention could stop progression of the problems and therefore benefit society. The diagnosis itself would require more symptoms than in DSM-IV and those would have to produce clinically significant issues. They denied there would be a new NOS behavioral category other than gambling disorder and noted prior DSM versions had a variant of that diagnosis.

Referring back to the 2004 publication of the NESARC study (the National Epidemiologic Survey on Alcohol and Related Conditions) headed by NIH's Dr. Bridget Grant, PhD, PhD (she has a double PhD in psychology and epidemiology), the APA's Work Group noted their recent analysis of her 43,000-subject project showed no significant change in prevalence. The APA feels it is our healthcare system, not our diagnostic criteria, that determines access to care. The new criteria would include gradations from mild to severe and their take is that this, not the distinction between abuse and dependence, is what is most crucial in improving both prevent and treatment. The APA feels the proposed new health legislation, not the changes to be seen in DSM-5, would expand quantity and quality of therapy.

Others have noted, however, that the APA makes ~$5 million a year from publishing the DSM and APA individual members could profit considerably from the increased number of patients the new guidelines could bring to their practices.

When does the cocktail-hour fan become the twenty-four-hour-a-day drunk?

The July 27, 2012 edition of Psychiatric Times had an article on "Substance Abuse in Aging and Elderly Adults." This arena is often overlooked or forgotten, but as of 2009 the "elderly" made up nearly 13% of the US population and a quarter of all prescription drugs sold in this country go to that group. When data from a 2009 National Survey on Drug Use and Health performed by SAMHSA, the Substance Abuse and Mental Health Services Administration, were examined, there were marked increases in illicit drug use in older adults. For those over 50, alcohol is the most common substance abused, but opiates were the second ,while anti-anxiety drugs and skeletal muscle relaxants were also on the commonly misused list.

The bottom line, I think, is that substance abuse is common, seen at all ages from youth to the elderly, and a significant problem in this country. There is considerable debate, even among experts in the field as to what criteria should be applied in diagnosing this problem and Dr, Allen's comments on the APA's role in crafting DSM should be taken seriously.

I'm still traveling, but back in the swing of writing posts on the numerous changes to DSM-5 the Diagnostic and Statistical Manual of Mental Disorders, that is supposed to be published (finally) in May of 2013. I've been reading background material, papers with advance critiques and older criteria for some of the diagnoses.

I still can't add photos as I'll be using my iPad until I get home four days from now, so I'll give you a URL or two and some titles you can Google.

I'll start with mentioning a long, multi-part fascinating paper that is appearing in 'Philosophy, Ethics and Humanities in Medicine'. It's called "The six most essential questions in psychiatric diagnosis: a pleuralogue." The second author, Allen Frances, a Duke School of Medicine Emeritus Professor of Psychiatry, was the leader of the group that put together DSM-IV. I'll come back to these articles in a later post, but used the first one to find short commentaries on DSM-5.

The lead author, Dr. James Phillips, is an Associate Clinical Professor of Psychiatry at Yale. In November, 2011 he wrote an article for 'Psychiatric Times,' titled "The Great DSM-5 Personality Bazaar," and in March of 2012, in the same publication, a piece titled "DSM-5 In the Homestretch--1. Integrating the Coding Systems."

That first piece told of diagnoses, e.g., narcissistic personality disorder, that were excluded in drafts of the new manual and later re-included. The total number of Personality Disorders ended up at six, down from ten, at the time Dr. Phillips wrote his commentary.

One category that was removed was Paranoid Personality Disorder. It seemed worthy of inclusion to Phillips, certainly as much so as another that was kept. Personality Disorder NOS (not otherwise specified), was apparently changed to Personality Disorder Trait Specified (PDTS), which to me at least is a potentially confusing acronym. There is PTSD after all, a term most of us have some familiarity with.

Dr. Mark Zimmerman et al. published a study of 2,150 psychiatric outpatients (you can find it at www.ncbi.nim.nih.gov/pubmed/21903031) which said that DSM-IV's method, using three trait categories: absent, sub threshold or present, was just as effective as the proposed diagnostic approach of DSM-5.

Dr. Phillips, in his later article, mentioned coding, how to relate the International Classification of Diseases (ICD) with the DSM, often for billing purposes. Our country has a treaty obligation to use the ICD and at present is using a "clinical modification" of the 1978 ICD-9 version. Some diagnoses used by US mental health (MH) therapists aren't in the ICD at all and the new American version of the international coding system, ICD-10CM, originally supposed to be available in October 2013, has been delayed. Of course the rest of the world already uses ICD-10.

Dr Frances in an April 25, 2012 piece in the New York Times, "Diagnosing the DSM-5: Shrink Revolt," was said to be opposed to the first draft of the new version as being too promiscuous with its diagnostic labels. He cites the proposed Binge Eating Disorder which may be present in 6% of the total US population (using the proposed definition).

He then commented, "And that is before the drug companies start marketing something for it."

He had similar reservations about three other tentative new DSM labels: one could be applied to kids with "typical temper problems;" another to anyone who has lost a spouse and is grief-stricken for two weeks. The third, "Psychosis Risk Syndrome," in his opinion, could misidentify many youngsters and treat others with anti-psychotic meds without any evidence that such early treatment is helpful.

By the May, 2012 meeting of the American Psychiatric Association (APA), two of those four problematic categories had been discarded. Dr Francis was still not content and published a NYT Op-Ed piece on May 11th titled "Diagnosing the D.S.M.," which said it's time to open the DSM's revision to all the MH disciplines as well to the primary care doctors who prescribe most of the drugs used for MH disorders.

It won't be published in its final official form until May of 2013, but the new version of the Diagnostic and Statistical Manual of Mental Disorders, AKA DSM-V, has already spawned lots of critiques and courses.

My wife, still doing some pro bono therapy, gets at least one offer a week to attend a seminar on DSM-V. I glance at those, but spend much more time on the background comments, including those from the lead editor of DSM-IV.

But let's start with the Rosenhan experiments. In 1973 an academic who was professor of psychology and law at Stanford had eight sane participants (himself among them) present to 12 hospital admission offices in five states with a chief complaint of "hearing voices." They said the messages conveyed were often unclear, but contained the words "empty," "hollow," and "thud."

In each case the voice was unfamiliar and of the same gender as the complainant (the group included one younger psychology graduate student, three professional psychologists, one psychiatrist, a pediatrician, a painter and a housewife). They gave false names, vocations and employment history, but all other details of their lives were true.

All were admitted to psychiatric wards, whereupon they acted completely sane and behaved as they normally would.

None of the staff recognized they were normal and 10 of them were given the diagnosis of schizophrenia. They remained in the hospital for a week to 52 days (average of 19 days) where a number of other patients suspected they were sane (35 of 118 did so with many vocalizing that the so-called patients were journalists or professors).

When the results of the study were initially made known, the staff of a week-known teaching/research hospital said they wouldn't make such mistakes.

At that point, Dr. Rosenhan set up a second experiment, telling the staff of the renowned center that he would send them one or more spurious patients over the next three months.

In reality he sent nobody, yet the hospital staff, suspected a number of the 193 patients who were admitted during that time frame; the physicians, psychologists, nurses and techs alleged that 41 were fakes and, of those, 23 were suspected by one or more psychiatrists.

During their admissions all of the first group publicly took copious notes and the typical comment in the nursing notes was "Patient engaged in writing behavior."

They were only discharged with a diagnosis of schizophrenia in remission after admitting they were crazy and all were given medications (which they did not swallow; they noted many patients did the same).

They seldom saw physicians except for fleeting encounters; in only 6% of these did staff doctors stop and chat or talk with them.

One comment about this famous study is, "It's hard to be sane in an insane setting?

Sorry, I can't give you links or photos, but I'm on an unplanned trip and using my iPad instead of my laptop.